1 1130ALL0213

Four Steps for Pharmacy Providers Medicare’s Limited Income Newly Eligible Transition (NET) Program is designed to eliminate any gaps in coverage for low-income individuals transitioning to Medicare Part D drug coverage. Enrollment in the Limited Income NET Program is temporary while Medicare randomly enrolls these individuals in a standard Medicare Part D plan for the future or the individual elects a Part D Plan of their choosing.

Point-of-sale prescription drug coverage: The Limited Income NET Program ensures that individuals with Medicare’s low-income subsidy (LIS), or “Extra Help,” who are not yet enrolled in a Part D prescription drug plan are still able to obtain immediate prescription drug coverage. (If an individual is later determined to be ineligible because he/she does not receive LIS, or any other reason the individual will be financially responsible for any claims already paid on his/her behalf.)

Retroactive prescription drug coverage: The Limited Income NET Program provides retroactive coverage for new dual eligibles (those individuals who are eligible for both Medicare and Medicaid or Medicare and Supplemental Security Income (SSI) from the Social Security Administration (SSA)). Medicare automatically enrolls these individuals into the Limited Income NET Program for eligible periods with an effective date retroactive to the start of their full-benefit, dual-eligible status. See page 3 for additional information on retroactive claims.

The Limited Income NET 4Rx data are printed at the top of the beneficiary’s confirmation letter from the Limited Income NET Program (if available). The data may also be obtained through an E1 query to Medicare’s on-line eligibility/enrollment query system, called the TrOOP Facilitator. The query will return the 4Rx data; if a phone number for contract “X0001” is returned, the beneficiary is enrolled in the Limited Income NET Program, but the 4Rx data are not yet available on Medicare’s system. In this case, use the following:

• BIN: 015599• PCN: 05440000• Cardholder ID: Medicare claim number on the red, white and blue Medicare Card (also

called Health Insurance Claim Number or HICN)• Group ID: may be left blank• Patient ID (optional): Medicaid ID or Social Security number

2

1130ALL0213

You should continue to perform an E1 query on these individuals monthly because Medicare will enroll them into a standard Medicare Part D plan within two months.

Using Medicare’s Limited Income NET Program: Four Steps 1. Request individual’s Medicare (Red, White, and Blue) ID card: 2. Submit an E1 transaction to Medicare’s online eligibility/enrollment system: Plan enrollment data are available for the 90 days prior to the query. If you are uncertain about how to submit an E1 query, please contact your software vendor. If the E1 query returns:

• BIN/PCN: submit the claim to the plan indicated • Contract ID number and help desk number: contact the plan for 4Rx data

If the E1 query does not return plan enrollment data, go to Step 3. 3. Verify eligibility for Medicaid or LIS through the following means:

• Medicaid ID card • Copy of current Medicaid award letter with effective dates • State eligibility verification system queries (interactive voice response, online) • Notice from Medicare or SSA awarding low-income subsidy

If the individual cannot provide evidence of current eligibility for Medicare and Medicaid or the LIS, do not submit a claim to the Limited Income NET Program. Instead, refer him/her to the State Health Insurance Assistance Program (SHIP) for help in obtaining such evidence. If the beneficiary has two days or less of medication left (or new Rx) he/she might qualify for an Immediate Need. The pharmacist will need to complete the fax form request and fax to 502-580-6644. Once the request has been received and validated, the pharmacy will receive a call back within 24 hours to process the immediate need request.

If the individual has Medicaid or LIS and Medicare eligibility, go to Step 4. 4. Submit claim to Medicare’s Limited Income NET Program: Enter the claim through your

claims system in accordance with the Limited Income NET payer sheet available at: www.humana.com/pharmacists/resources/li_net.asp.

• BIN: 015599 • PCN: 05440000

3

1130ALL0213

• Cardholder ID: Medicare claim number on the red, white and blue Medicare card (also called Health Insurance Claim Number or HICN)

• Group ID: may be left blank • Patient ID (optional): Medicaid ID or Social Security number

Common Claim Rejection Codes The following claims rejection messages will be returned to a pharmacy provider as secondary messages when an individual is determined to be ineligible. Error Description NCPDP

Rejection Code

Messaging and Pharmacy Guidance

Individual already enrolled in a Part D plan

41 Submit Bill to Other Processor or Primary Payer <custom message with patient and plan information>

Please submit claim to other Part D plan. If an unsuccessful attempt has been made to bill the other processor or payer, call 1-800-783-1307 for help.

Invalid Cardholder ID – individual not found with Medicare eligibility

52 Nonmatched Cardholder ID Unable to validate patient’s eligibility for Medicare; verify Medicare ID#; for additional help, call CMS at 1-800-MEDICARE

Enter Medicare claim number from red, white and blue Medicare card into cardholder ID field.

Claim older than 30 days with no established eligibility

52 Non-matched Cardholder ID Eligibility determination required; call 1-800-783-1307

Eligibility for program must be determined.

You must contact Humana at 1-800-783-1307 before you can process the claim.

No proof of LIS 16 Unable to validate Patients’ LIS eligibility - for more information call 800 < 783-1307>”

Additional information Medicare’s Limited Income NET Program will reimburse qualified individuals who paid for Part D prescription drugs out of pocket during eligible periods. Individuals can send or fax copies of their receipts to the Limited Income NET Program for review. Call 1-800-783-1307 for more information.

4

1130ALL0213

Medicare’s Limited Income NET Program has an open formulary. However drug categories excluded from Medicare Part D coverage by law or drugs used for an unapproved use are not payable under this program. Edits include those for safety, duplication, Part-B-covered drugs and Part-D-excluded drugs. If a pharmacist or beneficiary believes Limited Income NET rejected a claim in error, he may request an eligibility review and must provide proof of eligibility for the program. Call the Limited Income NET Program at 1-800-783-1307 for assistance. Visit www.cms.gov/LowIncSubMedicarePresCov/03_MedicareLimitedIncomeNET.asp for more information.

5

1130ALL0213

Calling Medicare’s Limited Income NET Program Main phone number: 1-800-783-1307 TTY phone number: 1-877-801-0369

Hours of operation: 8 a.m. to 8 p.m. local time, daily Our automated phone system may answer your call after 8 p.m. weekdays, as well as on Saturdays, Sundays and some holidays. Please leave a message when prompted with your name and telephone number. We will return your call by the end of the next business day. Menu Options

Pharmacy Provider: Press 1, then for: • Claim rejections: Press 1 • Part B vs. Part D Drug questions: Press 2 • Eligibility Verification: Press 3 • Repeat Options: Press 4

Physician/prescriber: Press 2 Beneficiaries/others: Press 3

6

1130ALL0213

Appendix: Additional Rejection Codes Error Description NCPDP

Rejection Code

NCPDP Primary Message

Secondary Message (Customizable)

Not currently Medicare eligible

65 Patient is not covered

Unable to validate patient’s eligibility for Medicare; verify Medicare ID number; for additional help, call CMS at 1-800-MEDICARE

Patient is deceased 65 Patient is not covered

Patient is shown to be deceased; verify Medicare ID number; for additional help, call CMS at 1-800-MEDICARE

Enrolled in a Medicare Part C plan

65 Patient is not covered

Enrolled in a Medicare Part C plan that does not allow enrollment in Limited Income NET; contact other plan

Patient has subsidized employer plan

65 Patient is not covered

Patient has subsidized employer/union group retiree drug benefits; not eligible for Limited Income NET; contact group plan

Patient opted out of Part D auto-enrollment

65 Patient is not covered

Patient has opted out of Part D auto-enrollment; not eligible for Limited Income NET; for additional help, call 1-800-783-1307

Patient lives outside the 50 states or DC

65 Patient is not covered

Patient lives outside of 50 states or District of Columbia; not eligible for Limited Income NET; verify address; for additional help, call 1-800-783-1307

Claim older than 36 months

75 Prior authorization required

Eligibility determination required; you will need to call Limited Income NET at 1-800-783-1307 before you can process the claim.

Missing required fields Various Various Required field(s) missing